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Do standing orders help with chronic disease care and health maintenance in ambulatory practice?
RESULTS ARE MIXED. Studies of standing orders tend to examine their effect on compliance with preventive interventions for chronic disease rather than disease outcomes. In the ambulatory setting, they improve rates of influenza vaccination (strength of recommendation [SOR]: C, consistent cohort studies measuring vaccination rates), pneumococcal vaccination (SOR: C, consistent randomized controlled trials [RCTs] measuring vaccination rates), childhood immunizations (SOR: C, inconsistent RCTs measuring vaccination rates), and mammograms (SOR: C, RCT measuring screening rate).
Standing orders don’t improve screening rates for colorectal cancer (SOR: C, RCT measuring screening rate).
Evidence summary
Organizational changes in physician offices can improve delivery of services for preventing and controlling disease.1 Standing orders—typically defined as physician-approved protocols that authorize nurses or other staff members to perform procedures, such as immunizations without direct physician involvement1—are readily applicable in ambulatory settings. However, only 30% of physicians use standing orders in their practices.2
Research on standing orders in ambulatory care has focused on immunizations and cancer screening (TABLE). Interventions implementing standing orders typically have multiple components and include staff education, chart flow sheets, and recall-reminders for patients.
TABLE
Effect of standing orders in ambulatory practice
| Disease | Standing order | Improvement in vaccination or screening rate | NNT* |
|---|---|---|---|
| Pneumococcal disease3-5 | Pneumococcal vaccine | Baseline range: 5%-15%; Follow-up range: 25%-28.3% | 3.7-10 |
| Influenza6-8 | Influenza vaccine | Baseline range: 32%-51.4%; Follow-up range: 58%-74.6% | 3.8-4.3 |
| Cancer screening3 | Mammogram | Baseline: 33%; Follow-up: 60% | 3.7 |
| Childhood illnesses9 | Immunizations, ages 2-5 yr | Baseline: 14%; Follow-up: 29% | 6.7 |
| *Number needed to treat (NNT) is based on the number of additional patients who receive an intervention based on the number who may be exposed to the standing order. | |||
Improvement in pneumococcal and flu vaccine rates
Three multicomponent RCTs of outpatient standing orders reported improved pneumococcal vaccination rates.3-5 Similarly, 2 prospective, multicomponent cohort studies6,7 and 1 retrospective study8 found improved rates of influenza vaccination with standing orders.
Childhood vaccination rates also show positive trends
Two controlled trials (1 randomized3 and 1 nonrandomized9) that incorporated standing orders examined their use in childhood immunizations (measles, mumps, and rubella [MMR]; oral polio vaccine [OPV]; Haemophilus influenzae, type b [HIB]; diphtheria and tetanus toxoids with acellular pertussis [DTaP]; and hepatitis B). One trial reported increased use of acute care immunization opportunities;9 the other showed a nonsignificant positive trend in vaccination rates.3
Standing orders increase 1 form of cancer screening, not another
A multicomponent RCT of standing orders for mammography and colorectal cancer screening found a statistically significant increase in screening for mammography, but not colorectal cancer.3
Recommendations
The Society of Adolescent Medicine recommends standing orders for administration of influenza vaccine during flu season.10
The Task Force on Community Preventive Services recommends standing orders for adult vaccinations based on “strong evidence,” but states that insufficient evidence exists to recommend standing orders for childhood vaccinations.11 Vaccines examined include MMR, DTaP, HIB, hepatitis B, and varicella for young children; hepatitis B, varicella, MMR, and tetanus-diphtheria toxoids (Td) for adolescents; Td for adults up to 65 years of age; and influenza and pneumococcal vaccines for adults 65 years and older.
The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention recommends standing orders for influenza and pneumococcal vaccines.12
1. Stone EG, Morton SC, Hulscher ME, et al. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med. 2002;136:641-651.
2. Nichol KL, Zimmerman R. Generalist and subspecialist physicians’ knowledge, attitudes, and practices regarding influenza and pneumococcal vaccinations for elderly and other high-risk patients: a nationwide survey. Arch Intern Med. 2001;161:2702-2708.
3. Mold JW, Aspy CA, Nagykaldi Z. Implementation of evidence-based preventive services delivery processes in primary care: an Oklahoma Physicians Resource/Research Network (OKPRN) study. J Am Board Fam Med. 2008;21:334-344.
4. Rhew DC, Glassman PA, Goetz MB. Improving pneumococcal vaccine rates. Nurse protocols versus clinical reminders. J Gen Intern Med. 1999;14:351-356.
5. Herman CJ, Speroff T, Cebul RD. Improving compliance with immunization in the older adult: results of a randomized cohort study. J Am Geriatr Soc. 1994;42:1154-1159.
6. Margolis KL, Nichol KL, Wuorenma J, et al. Exporting a successful influenza vaccination program from a teaching hospital to a community outpatient setting. J Am Geriatr Soc. 1992;40:1021-1023.
7. Nichol KL, Korn JE, Margolis KL, et al. Achieving the national health objective for influenza immunization: success of an institution-wide vaccination program. Am J Med. 1990;89:156-160.
8. Goebel LJ, Neitch SM, Mufson MA. Standing orders in an ambulatory setting increases influenza vaccine usage in older people. J Am Geriatr Soc. 2005;53:1008-1010.
9. Christy C, McConnochie KM, Zernik N, et al. Impact of an algorithm-guided nurse intervention on the use of immunization opportunities. Arch Pediatr Adolesc Med. 1997;151:384-391.
10. Kharbanda EO, Maehr J, Middleman AB, et al. Influenza vaccine: a position statement of The Society for Adolescent Medicine. J Adolesc Health. 2007;41:216-217.
11. Vaccine-preventable diseases: improving vaccination coverage in children adolescents and adults. A report on recommendations from the Task Force on Community Preventive Services. MMWR Recomm Rep. 1999;48(RR-8):1-15.
12. Harper SA, Fukuda K, Uyeki TM, et al. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2004;53 (RR-6):1-40.
RESULTS ARE MIXED. Studies of standing orders tend to examine their effect on compliance with preventive interventions for chronic disease rather than disease outcomes. In the ambulatory setting, they improve rates of influenza vaccination (strength of recommendation [SOR]: C, consistent cohort studies measuring vaccination rates), pneumococcal vaccination (SOR: C, consistent randomized controlled trials [RCTs] measuring vaccination rates), childhood immunizations (SOR: C, inconsistent RCTs measuring vaccination rates), and mammograms (SOR: C, RCT measuring screening rate).
Standing orders don’t improve screening rates for colorectal cancer (SOR: C, RCT measuring screening rate).
Evidence summary
Organizational changes in physician offices can improve delivery of services for preventing and controlling disease.1 Standing orders—typically defined as physician-approved protocols that authorize nurses or other staff members to perform procedures, such as immunizations without direct physician involvement1—are readily applicable in ambulatory settings. However, only 30% of physicians use standing orders in their practices.2
Research on standing orders in ambulatory care has focused on immunizations and cancer screening (TABLE). Interventions implementing standing orders typically have multiple components and include staff education, chart flow sheets, and recall-reminders for patients.
TABLE
Effect of standing orders in ambulatory practice
| Disease | Standing order | Improvement in vaccination or screening rate | NNT* |
|---|---|---|---|
| Pneumococcal disease3-5 | Pneumococcal vaccine | Baseline range: 5%-15%; Follow-up range: 25%-28.3% | 3.7-10 |
| Influenza6-8 | Influenza vaccine | Baseline range: 32%-51.4%; Follow-up range: 58%-74.6% | 3.8-4.3 |
| Cancer screening3 | Mammogram | Baseline: 33%; Follow-up: 60% | 3.7 |
| Childhood illnesses9 | Immunizations, ages 2-5 yr | Baseline: 14%; Follow-up: 29% | 6.7 |
| *Number needed to treat (NNT) is based on the number of additional patients who receive an intervention based on the number who may be exposed to the standing order. | |||
Improvement in pneumococcal and flu vaccine rates
Three multicomponent RCTs of outpatient standing orders reported improved pneumococcal vaccination rates.3-5 Similarly, 2 prospective, multicomponent cohort studies6,7 and 1 retrospective study8 found improved rates of influenza vaccination with standing orders.
Childhood vaccination rates also show positive trends
Two controlled trials (1 randomized3 and 1 nonrandomized9) that incorporated standing orders examined their use in childhood immunizations (measles, mumps, and rubella [MMR]; oral polio vaccine [OPV]; Haemophilus influenzae, type b [HIB]; diphtheria and tetanus toxoids with acellular pertussis [DTaP]; and hepatitis B). One trial reported increased use of acute care immunization opportunities;9 the other showed a nonsignificant positive trend in vaccination rates.3
Standing orders increase 1 form of cancer screening, not another
A multicomponent RCT of standing orders for mammography and colorectal cancer screening found a statistically significant increase in screening for mammography, but not colorectal cancer.3
Recommendations
The Society of Adolescent Medicine recommends standing orders for administration of influenza vaccine during flu season.10
The Task Force on Community Preventive Services recommends standing orders for adult vaccinations based on “strong evidence,” but states that insufficient evidence exists to recommend standing orders for childhood vaccinations.11 Vaccines examined include MMR, DTaP, HIB, hepatitis B, and varicella for young children; hepatitis B, varicella, MMR, and tetanus-diphtheria toxoids (Td) for adolescents; Td for adults up to 65 years of age; and influenza and pneumococcal vaccines for adults 65 years and older.
The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention recommends standing orders for influenza and pneumococcal vaccines.12
RESULTS ARE MIXED. Studies of standing orders tend to examine their effect on compliance with preventive interventions for chronic disease rather than disease outcomes. In the ambulatory setting, they improve rates of influenza vaccination (strength of recommendation [SOR]: C, consistent cohort studies measuring vaccination rates), pneumococcal vaccination (SOR: C, consistent randomized controlled trials [RCTs] measuring vaccination rates), childhood immunizations (SOR: C, inconsistent RCTs measuring vaccination rates), and mammograms (SOR: C, RCT measuring screening rate).
Standing orders don’t improve screening rates for colorectal cancer (SOR: C, RCT measuring screening rate).
Evidence summary
Organizational changes in physician offices can improve delivery of services for preventing and controlling disease.1 Standing orders—typically defined as physician-approved protocols that authorize nurses or other staff members to perform procedures, such as immunizations without direct physician involvement1—are readily applicable in ambulatory settings. However, only 30% of physicians use standing orders in their practices.2
Research on standing orders in ambulatory care has focused on immunizations and cancer screening (TABLE). Interventions implementing standing orders typically have multiple components and include staff education, chart flow sheets, and recall-reminders for patients.
TABLE
Effect of standing orders in ambulatory practice
| Disease | Standing order | Improvement in vaccination or screening rate | NNT* |
|---|---|---|---|
| Pneumococcal disease3-5 | Pneumococcal vaccine | Baseline range: 5%-15%; Follow-up range: 25%-28.3% | 3.7-10 |
| Influenza6-8 | Influenza vaccine | Baseline range: 32%-51.4%; Follow-up range: 58%-74.6% | 3.8-4.3 |
| Cancer screening3 | Mammogram | Baseline: 33%; Follow-up: 60% | 3.7 |
| Childhood illnesses9 | Immunizations, ages 2-5 yr | Baseline: 14%; Follow-up: 29% | 6.7 |
| *Number needed to treat (NNT) is based on the number of additional patients who receive an intervention based on the number who may be exposed to the standing order. | |||
Improvement in pneumococcal and flu vaccine rates
Three multicomponent RCTs of outpatient standing orders reported improved pneumococcal vaccination rates.3-5 Similarly, 2 prospective, multicomponent cohort studies6,7 and 1 retrospective study8 found improved rates of influenza vaccination with standing orders.
Childhood vaccination rates also show positive trends
Two controlled trials (1 randomized3 and 1 nonrandomized9) that incorporated standing orders examined their use in childhood immunizations (measles, mumps, and rubella [MMR]; oral polio vaccine [OPV]; Haemophilus influenzae, type b [HIB]; diphtheria and tetanus toxoids with acellular pertussis [DTaP]; and hepatitis B). One trial reported increased use of acute care immunization opportunities;9 the other showed a nonsignificant positive trend in vaccination rates.3
Standing orders increase 1 form of cancer screening, not another
A multicomponent RCT of standing orders for mammography and colorectal cancer screening found a statistically significant increase in screening for mammography, but not colorectal cancer.3
Recommendations
The Society of Adolescent Medicine recommends standing orders for administration of influenza vaccine during flu season.10
The Task Force on Community Preventive Services recommends standing orders for adult vaccinations based on “strong evidence,” but states that insufficient evidence exists to recommend standing orders for childhood vaccinations.11 Vaccines examined include MMR, DTaP, HIB, hepatitis B, and varicella for young children; hepatitis B, varicella, MMR, and tetanus-diphtheria toxoids (Td) for adolescents; Td for adults up to 65 years of age; and influenza and pneumococcal vaccines for adults 65 years and older.
The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention recommends standing orders for influenza and pneumococcal vaccines.12
1. Stone EG, Morton SC, Hulscher ME, et al. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med. 2002;136:641-651.
2. Nichol KL, Zimmerman R. Generalist and subspecialist physicians’ knowledge, attitudes, and practices regarding influenza and pneumococcal vaccinations for elderly and other high-risk patients: a nationwide survey. Arch Intern Med. 2001;161:2702-2708.
3. Mold JW, Aspy CA, Nagykaldi Z. Implementation of evidence-based preventive services delivery processes in primary care: an Oklahoma Physicians Resource/Research Network (OKPRN) study. J Am Board Fam Med. 2008;21:334-344.
4. Rhew DC, Glassman PA, Goetz MB. Improving pneumococcal vaccine rates. Nurse protocols versus clinical reminders. J Gen Intern Med. 1999;14:351-356.
5. Herman CJ, Speroff T, Cebul RD. Improving compliance with immunization in the older adult: results of a randomized cohort study. J Am Geriatr Soc. 1994;42:1154-1159.
6. Margolis KL, Nichol KL, Wuorenma J, et al. Exporting a successful influenza vaccination program from a teaching hospital to a community outpatient setting. J Am Geriatr Soc. 1992;40:1021-1023.
7. Nichol KL, Korn JE, Margolis KL, et al. Achieving the national health objective for influenza immunization: success of an institution-wide vaccination program. Am J Med. 1990;89:156-160.
8. Goebel LJ, Neitch SM, Mufson MA. Standing orders in an ambulatory setting increases influenza vaccine usage in older people. J Am Geriatr Soc. 2005;53:1008-1010.
9. Christy C, McConnochie KM, Zernik N, et al. Impact of an algorithm-guided nurse intervention on the use of immunization opportunities. Arch Pediatr Adolesc Med. 1997;151:384-391.
10. Kharbanda EO, Maehr J, Middleman AB, et al. Influenza vaccine: a position statement of The Society for Adolescent Medicine. J Adolesc Health. 2007;41:216-217.
11. Vaccine-preventable diseases: improving vaccination coverage in children adolescents and adults. A report on recommendations from the Task Force on Community Preventive Services. MMWR Recomm Rep. 1999;48(RR-8):1-15.
12. Harper SA, Fukuda K, Uyeki TM, et al. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2004;53 (RR-6):1-40.
1. Stone EG, Morton SC, Hulscher ME, et al. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med. 2002;136:641-651.
2. Nichol KL, Zimmerman R. Generalist and subspecialist physicians’ knowledge, attitudes, and practices regarding influenza and pneumococcal vaccinations for elderly and other high-risk patients: a nationwide survey. Arch Intern Med. 2001;161:2702-2708.
3. Mold JW, Aspy CA, Nagykaldi Z. Implementation of evidence-based preventive services delivery processes in primary care: an Oklahoma Physicians Resource/Research Network (OKPRN) study. J Am Board Fam Med. 2008;21:334-344.
4. Rhew DC, Glassman PA, Goetz MB. Improving pneumococcal vaccine rates. Nurse protocols versus clinical reminders. J Gen Intern Med. 1999;14:351-356.
5. Herman CJ, Speroff T, Cebul RD. Improving compliance with immunization in the older adult: results of a randomized cohort study. J Am Geriatr Soc. 1994;42:1154-1159.
6. Margolis KL, Nichol KL, Wuorenma J, et al. Exporting a successful influenza vaccination program from a teaching hospital to a community outpatient setting. J Am Geriatr Soc. 1992;40:1021-1023.
7. Nichol KL, Korn JE, Margolis KL, et al. Achieving the national health objective for influenza immunization: success of an institution-wide vaccination program. Am J Med. 1990;89:156-160.
8. Goebel LJ, Neitch SM, Mufson MA. Standing orders in an ambulatory setting increases influenza vaccine usage in older people. J Am Geriatr Soc. 2005;53:1008-1010.
9. Christy C, McConnochie KM, Zernik N, et al. Impact of an algorithm-guided nurse intervention on the use of immunization opportunities. Arch Pediatr Adolesc Med. 1997;151:384-391.
10. Kharbanda EO, Maehr J, Middleman AB, et al. Influenza vaccine: a position statement of The Society for Adolescent Medicine. J Adolesc Health. 2007;41:216-217.
11. Vaccine-preventable diseases: improving vaccination coverage in children adolescents and adults. A report on recommendations from the Task Force on Community Preventive Services. MMWR Recomm Rep. 1999;48(RR-8):1-15.
12. Harper SA, Fukuda K, Uyeki TM, et al. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2004;53 (RR-6):1-40.
Evidence-based answers from the Family Physicians Inquiries Network